Covered Medical Services/ In-Network Out of-Network 2 Plan Design Features Payment Payment* 4 Specialist (office visits) 100% 80% after 5 deductible 7 Surgery 100% 80% after 8 deductible 10 Physician in-hospital services 100% 80% after 11 deductible 12 13 Allergy testing and treatment 100% 80% after 14 deductible 15 16 Allergy injections 100% 80% after 17 deductible 18 19 Immunizations and injections 100% 80% after 20 deductible 21 (immunizations at 22 100% with 23 deductible waived 24 for children, birth 25 to age 6) 26 27 Other physician services 100% 80% after 28 deductible 30 Maternity (coverage includes 100% 80% after 31 voluntary sterilization and deductible 32 voluntary abortion) 33 34 Contraceptives (including 100% 80% after 35 injectable contraceptives that deductible 36 are not self-administered and 37 inserted and implanted contra- 38 ceptive devices) 39 40 *Once both the annual (calendar year) deductible and the coinsurance limit (a combined total of $850 per individual or 41 $1,800 per family) have been reached, all medical services received out-of-network for the remainder of the calendar 42 year are benefited at 100% (except for: prescription co-pays; coinsurance payments for outpatient mental health, 43 outpatient alcohol/drug abuse, and non-emergency use of emergency room services; and penalty payments).
Covered Medical Services/ In-Network Out of-Network 2 Plan Design Features Payment* Payment* 4 Contraceptives (including 90% after deductible 80% after 5 injectable contraceptives that deductible 6 are not self-administered and 7 inserted and implanted contra- 8 ceptive devices) 10 Infertility Treatment 90% after deductible 80% after 11 Artificial insemination (6 cycles deductible 12 lifetime maximum). Advanced 13 reproductive technology, including 14 in vitro fertilization, GIFT, ZIFT 15 to lifetime maximum of $30,000. 17 Diagnostic X-Ray & Laboratory 90% after deductible 80% after 18 (other than physician's office) deductible 19 20 Durable Medical Equipment 90% after deductible 80% after 21 deductible
Covered Medical Services/ In-Network Out of-Network 2 Plan Design Features Payment* Payment* 4 Mail-order pharmacy program 100% after $10 generic N/A 5 (Medco) and $20 brand co-pay 6 for a 90-day supply 8 Mental Health Services 9 Inpatient coverage 90% after deductible 80% after 10 up to 120 days per deductible up to 11 calendar year*** 40 days per 12 calendar year*** 14 Outpatient coverage 90% after deductible** 80% after 15 (including all mandated up to 120 visits per deductible** up to 16 providers) calendar year*** 30 visits per 17 calendar year*** 18
Covered Medical Services/ In-Network Out of-Network 2 Plan Design Features Payment* Payment* 4 Claim Submission Provider initiated. Member initiated, 5 Two-year filing member 6 requirement ultimately 7 responsible.
Covered Medical Services/ In-Network Out of-Network 2 Plan Design Features Payment Payment*
Covered Medical Services/ In-Network Out of-Network 2 Plan Design Features Payment Payment* 4 Mental Health Services 5 Inpatient coverage 100% up to 120 days 80% after 6 per calendar year**** deductible up to 7 40 days per 8 calendar year**** 10 Outpatient coverage 100% up to 120 visits 80% after 11 (including all mandated per calendar year**** deductible** up to 12 providers) 30 visits per 13 calendar year****
Covered Medical Services/ In-Network Out of-Network 2 Plan Design Features Payment Payment* 4 Organ Transplants (see National 100% 80% after 5 Program for Medical Excellence) deductible 7 Physical/Speech/Occupational 100% 80% after 8 Therapy (inpatient and out- deductible 9 patient) 10 11 Radiation Therapy (inpatient and 100% 80% after 12 outpatient) deductible 13 14 Chemotherapy (inpatient and out- 100% 80% after 15 patient) deductible 16 17 Blood/Blood Plasma 100% 80% after 18 deductible 20 Chiropractic 100% up to 50 visits 80% after 21 per calendar year*** deductible up to 22 50 visits per 23 calendar year*** 24 25 Oral Surgery (procedures covered 100% 80% after 26 by Aetna U.S. Healthcare on deductible 27 October 27, 2000) 28 29 TMJ (surgical and non-surgical 100% 80% after 30 diagnosis and treatment) deductible 31 32 Prosthetic/Orthotic Appliances 100% 80% after 33 deductible 34
